Infections significantly influence the morbidity and mortality rates of
intensive care units (ICUs), and the prevalence and impact of severe infections
in critically ill patients have increased progressively in recent years.(1,2) In addition, more than 70% of critically ill patients admitted to ICUs
are prescribed an antimicrobial agent during their stay.(1)

Unfortunately, the actual
situation in Brazil is difficult to assess because high-quality data on the
local conditions are scarce in the literature. The few studies that sought to retrieve
Brazilian data on infections and sepsis reported extremely important results,
showing that both the prevalence and the lethality associated with infection in
critically ill patients is high compared to the values reported in the
international literature. For instance, the mortality rate of patients in
Brazil with septic shock is greater than 50%.(3-5) The reasons
underlying such unfavorable outcomes are unclear; however, organizational
issues and early detection are certainly important features in such an
assessment.

This issue of the Brazilian
Journal of Intensive Care (Revista Brasileira de Terapia Intensiva  RBTI)
includes an article that is crucial for a better understanding of the current
status of sepsis and infections in critically ill patients.(6) This
study performed a sub-analysis of EPIC II (Extended Prevalence of Infection in
Intensive Care), which is a cross-sectional study that included 13,796
patients, more than 9,000 patients who received antimicrobial agents and
approximately 7,000 patients who were diagnosed as infected. The sub-analysis
assessed only patients in Brazil and provides precise, high-quality data on the
prevalence and characteristics of the patients admitted to Brazilian ICUs. More
than 1,200 patients admitted to 90 ICUs across Brazil were included for
analysis in this sub-analysis, which is currently the largest study of its type
in the literature.

Some data in the
cross-sectional study are worth noting. Approximately 62% of the patients
admitted to Brazilian ICUs presented with clinical evidence of infection; this
prevalence is significantly higher than the prevalences reported by the same
database for other areas, such as Europe and North America (where the
prevalence is less than 50%).(1) In addition to higher prevalence,
our ability to identify the etiology of infection is poor; thus, the pathogens
that were potentially responsible for the infection were isolated in only 50%
of the cases. The most frequent site of infection was the respiratory system
(61%). The distribution of the pathogens associated with infection in Brazilian
ICUs is also worth noting for several reasons. Brazil has a higher prevalence
of Gram-negative agents compared to other areas
(especially the most developed regions), which is consistent with other
reports.(5)

Although the ICU (37.6%) and
in-hospital (44.2%) mortality rates of patients with infection are lower than
those in previously published reports, they are still high compared to the
international data, especially the data from developed areas such as Western
Europe, North America, and Australia. In addition, there is a patent
correlation between infection and mortality, resulting in a higher lethality
than with other clinical conditions whose severity and correlation with
unfavorable outcomes are widely acknowledged (e.g., acute myocardial infarction
and stroke).

Another feature must also be
considered to better understand the reasons for the differences found in the
clinical outcomes, mortality in particular, when comparing the Brazilian and
the international data. An important fraction of the patients exhibited at
least one comorbidity upon admission, which is consistent with the available
international data. However, the data supplied by Silva et al. show high
prevalence of organ dysfunction at admission. Nearly two-thirds of the patients
exhibited respiratory dysfunction. Although that finding is consistent with the
international data, the rate is higher than the prevalence of dysfunction in
developed countries.(3)

Two complementary solutions
may be provided for this situation: an earlier identification of the patients
who may benefit from intensive care and a greater availability of resources
(beds, equipment, and human resources) to provide intensive care to such
patients. Optimization of both solutions through educational and training
strategies allowing for the early identification of patients and increasing the
quantity and more importantly the quality of available resources may have the
greatest potential to affect the outcomes of patients with infections in the
ICU. Unfortunately, one limitation of the study concerns its ability to assess
infection management because the excessive mortality found in Brazil is not
explained by the severity of the patients' primary disease alone, thus
suggesting that specific management features may be associated with the
unfavorable outcomes.

Such data provide an accurate
picture of infection in Brazilian ICUs and represent an important step in
identifying the reasons for the high prevalence and associated morbidity and
mortality of infections in the ICU. These findings must be included in the
design of institutional strategies and public policies aimed at optimizing the
use of resources, continued education, and training of human resources to understand
and modify the outcomes of patients with an infection who are admitted to ICUs.